Deductible, coinsurance and copay represent what you pay. All coinsurance amounts are based on maximum allowable amounts.
Benefits apply after calendar year deductible is met, unless otherwise noted as “no deductible,” “copay,” or “covered in full.” PCY = Per Calendar Year
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WiseChoices |
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Preferred Providers |
Non-Preferred & extended providers |
Annual Deductible PCY (choose one)
(Family is 3x the individual deductible)* |
Individual: $500 / $1,000 / $2,500 / $5,000 |
2x individual deductible |
| Coinsurance1 (what you pay) |
20% |
50% |
Annual Coinsurance Maximum
(family = 2x individual) |
$7,500 |
Unlimited |
| Out-of-Pocket Maximum |
Annual deductible + coinsurance maximum |
| Office Visit Cost Share |
$20 Copay per visit |
Deductible applies first, then you pay 50% |
| Lifetime Maximum |
$2,000,000 |
| Covered Services |
Preferred Providers |
Non-Preferred & extended providers |
| Preventive Care
|
Preventive Care Exams
(routine medical exam, sports
physical and women’s health exams/well baby)2 |
$20 Copay per visit |
Deductible applies first, then you pay 50% |
Preventive Screenings
(includes Pap smear, PSA
testing, home colon cancer screening, cholesterol
screening and bone density test) |
Covered in full2 |
| Immunizations |
| Professional Care
|
| Office Visit including Urgent Care |
$20 Copay per visit |
Deductible applies first, then you pay 50% |
| Other Outpatient and Inpatient Professional Services |
Deductible applies first, then you pay 20% |
| Alternative Care
|
Spinal and Other Manipulations 12 visits PCY
(visits
shared with Acupuncture) |
$25 Copay per visit |
Deductible applies first, then you pay 50% |
Acupuncture 12 visits PCY
(visits shared with Spinal and
Other Manipulations) |
| Naturopathy |
$20 Copay per visit |
| Diagnostic Services
|
| Outpatient Diagnostic Imaging and Lab Services |
Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Mammography |
Covered in full2 |
| Pharmacy
|
| Retail Pharmacy (30-day supply) |
$20 Generics; 50% Brand |
Preferred cost share + 40% |
| Mail Service Pharmacy (90-day supply) |
$50 Generics; 45% Brand |
| Emergency Care
|
| Emergency Room Care (copay waived if direct admit to an inpatient facility) |
$100 Copay per visit;
Deductible applies first, then you pay 20% |
| Ambulance Transportation Air (unlimited); Ground ($5,000 PCY limit) |
Deductible applies first, then you pay 20% |
| Facility Care
|
| Inpatient Facility Care |
Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Outpatient Facility Care |
| Skilled Nursing Facility 45 days PCY; includes room and
board, ancillaries and professional fees |
| Maternity
|
| Maternity Care |
Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Vision Care
|
| Routine Vision Exam |
Covered in full2 |
| Vision Hardware |
$200 for frames, lenses and contact lenses |
| Other Services
|
| Supplies, Equipment and Prosthetics $5,000 PCY |
Deductible applies first, then you pay 20% |
Deductible applies first, then you pay 50% |
| Home Health Care 130 visits PCY |
| Hospice Care Inpatient: 10 days, Respite: 240 hours
per 6 months lifetime maximum |
| Rehabilitation (includes Physical, Occupational & Speech
Therapy, Cardiac & Pulmonary Rehab; & Chronic Pain)
Outpatient: 20 visits PCY; Inpatient: 8 days PCY |
| Transplants (Organ & Bone Marrow) 12-month
waiting period; $250,000 Lifetime Benefit |
| Accident Benefit $1,000 PCY |
First $1,000 is covered in full2 PCY; then paid as any other illness subject to deductible/coinsurance |
| Alcohol Dependency Treatment |
This optional benefit is available at an additional cost. It is limited to $4,500 in any 24 consecutive months |
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* Family = Individual plus one or more family members
1 All coinsurance amounts are the member’s percentage of maximum allowable amounts after deductible
2 Benefits provided at 100% of maximum allowable amounts; not subject to deductible or coinsurance.
This is only a summary of major benefits. It is not a contract. |
Plan Updates 
